1. Traumatic Brain Injury
Zara Melikyan, Ph.D.
Fall 2015

2. Lecture Plan TBI problem significance TBI causes
Definitions: TBI, concussion, DAI
TBI mechanism
TBI classification
TBI symptoms
TBI diagnosis
TBI treatment, rehabilitation
TBI prognosis
TBI prevention

3. TBI Problem Significance
TBI is a major social, economic, health problem
Major cause of death and disability
Epidemiology in the US
52,000 deaths
1.5 million head injuries reported in ER
5.3 million (2%) with TBI-related disabilities
Moderate & severe head injury associated with increased risk of AD

4. TBI Problem Significance
Mostly affects children and young adults
Males > females sustain TBI
Milder cases undiagnosed and untreated
May cause long-lasting/disabling deficits

5. TBI Causes Falls (e.g., construction) Vehicle accidents
Violence, abuse
Sports
War

6. Definitions
Traumatic brain injury = intracranial injury – injury to the brain
Head injury – injury to the brain + other parts of the head (i.e. scalp, scull)
Concussion – (from “concutere” = shake violently) most common type of TBI
Diffuse axonal injury – brain injury, damage to white matter, brain tracts

7. TBI Mechanism External force injures the brain:
Sudden acceleration/deceleration within the cranium
Impact
Blast waives
Penetration
Impact + acceleration

8. TBI Mechanism Contact – head struck by smth – focal injuries
Non-contact – moving brain within the skull – diffuse injuries
E.g. shaken baby syndrome
Coup injury – injury under the site of impact
Counter-coup injury

9. TBI Mechanism Type of force Direction of forces Intensity of forces
Duration of forces
Types of forces:
Angular
Rotational
Shear
Translational

10. Lecture Plan TBI problem significance TBI causes
Definitions: TBI, concussion, DAI
TBI mechanism
TBI classification
TBI symptoms
TBI diagnosis
TBI treatment, rehabilitation
TBI prognosis
TBI prevention

11. Primary and Secondary TBI
Primary injury – damage that occurs at the moment of trauma (tissues and blood vessels stretched, compressed, torn)
Secondary injury – biochemical cascade of events minutes – days following injury:
Alterations in cerebral blood flow: ischemia, hypoxia
Edema
Changes of pressure within the scull
BBB damage

12. TBI Classification Severity Injury mechanism
Closed/non-penetrating/blunt
Penetrating
Anatomical features of the injury
GCS
PTA
LOC
Mild
13-15
<1 day
0-30 min
Moderate
9-12
1-7 days
30min-24 hours
Severe
3-8
>7 days
>24 hours

13. Assessment of Level of Consciousness Glasgow Coma Scale
Eyes opening
Verbal
Motor 1
Does not open
No sounds
No movements 2
In response to pain
Incomprehensible sounds
Extension to pain 3
In response to voice
Inappropriate words
Abnormal flexion to pain 4
Spontaneously
Confused, disoriented
Withdrawal to pain 5
N/A
Normal
Localizes painful stimuli 6
Obeys commands
Interpretation
Severe GCS <8-9
Moderate GCS 8 – 9-12
Minor >=13

14. Levels of Consciousness
Summary
Metaconscious
Monitor and control own cognitive processes. Prefrontal cortex
Conscious
Normal. Orientation X3 (self, place, time). Sleep
Confused
Disoriented, slow to orient, difficulty following instructions
Delirious
Disoriented, restless, agitated, hallucinations, delusions
Metaconscious - People who possess the ability to monitor and control their own cognitive processes in addition to meeting all the criteria indicative of a normal level of consciousness. In the field of cognitive neuroscience, metacognitive monitoring and control have been viewed as functions of the prefrontal cortex, which receives sensory input signals from divergent cortical regions and implements control through feedback loops which are established utilizing the underlying mechanisms of neuroplasticity (see chapters by Schwartz & Bacon and Shimamura, in Dunlosky & Bjork, 2008).
Conscious - Assessment of LOC involves checking orientation: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3".[8] A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness.[9] "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness.
Confused - People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "confused".[8] A confused person may be bewildered, disoriented, and have difficulty following instructions.[9] The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection.
Delirious - Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in attention

15. Levels of Consciousness
Summary
Somnolent
Sleepy, drowsy, slow and disorganized response to stimuli
Obtunded
Decreased alertness, slow responses, sleepiness, decreased interest in surroundings
Stuporous
Sleep-like state, no spontaneous activity, respond only to painful stimuli
Comatose
Can not be aroused no response to stimuli. No corneal/gag reflex, may not have pupillary response to light
Somnolent - A somnolent person shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements.[8]
Obtunded - In obtundation, a person has a decreased interest in their surroundings, slowed responses, and sleepiness
Stuporous - People with an even lower level of consciousness, stupor, only respond by grimacing or drawing away from painful stimuli
Comatose - Comatose people do not even make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light.

16. First/Transient Symptoms After TBI
Loss of consciousness (LOC)
Headache
Vomiting
Nausea
Dizziness
Balance problems
Lack of motor coordination
Lightheadedness
Blurred vision
Tinnitus (ringing in ears)
Fatigue, lethargy
Change in sleep pattern

17. Longer Lasting Impairments Following TBI
Physical
Damage of the brain – intra-axial
Damage in the skull but outside of the brain – extra-axial
Swelling (edema)
Increased intracranial pressure
Hematoma (blood collection): epidural. subdural
Hemorrhage (bleeding): subarachnoid, intraventricular
Focal lesions
Orbitofrontal cortex
Anterior temporal lobes
Diffuse injury - DTI

18. Longer Lasting Impairments Following TBI
Cognitive
Memory: PTA, short-term memory
Language
Executive function: decision making
Alexithymia
Motor
Social
Emotional (regulation)
Behavioral

19. Diagnosis Neurological examination Neuroimaging
Computerized tomography (CT)
Magnetic resonance imaging (MRI)
Neuropsychological testing of cognitive, emotional, behavioral changes after TBI

20. Normal Brain Imaging

21. TBI Brain Imaging

22. TBI Brain CT - Hematoma

23. TBI Brain CT – Intracerebral Hemorrhage

24. TBI Brain CT – Subarachnoid Hemorrhage

25. TBI Brain CT – Diffuse Axonal Injury

26. TBI Brain Imaging

27. TBI Treatment & Rehabilitation
Acute stage, “golden hour”:
Stabilize: O2, blood flow, ICP
Prevent further injury
Surgery
Medications
Rest
Prevent seizures

28. TBI Treatment & Rehabilitation
Subacute, chronic stages:
Multidisciplinary team: impatient/outpatient
Neurology
Psychiatry
Physical therapy
Speech therapy
Recreation therapy
Occupational therapy
Cognitive rehabilitation
Counseling
Supported employment

29. Prognosis The more severe the injury the worse the prognosis
Permanent disability:
Mild injuries – 10%
Moderate injuries – 66%
Severe injuries – 100%

30. TBI Prevention Protection from accidents: belts, helmets
Changes in sports practice – helmets
Environmental changes
For elderly: grab bars in bathroom, rails; remove tripping hazards
For children: safety gates, shock-absorbing surfaces
Safety education
Enforcement of law
Abuse prevention

31. Thank you!